[Efficiency and safety of silodosin for treatment of lower urinary tract symptoms, associated of benign prostatic hyperplasia].

Benign prostatic hyperplasia commonly is the most common cause of bladder outlet obstruction and can result in storage and micturition symptoms in men older than 40 years. Nowadays the 1-adrenoreceptor antagonists are the first-line drug for treatment of the lower urinary tract symptoms (LUTS). However, 1-adrenoreceptors are known to be present in other tissues and this fact could be a reason of potential risk of adverse events, associated with changes in peripheral vascular tone, such as orthostatic hypotension, syncopal states, dizziness, etc., especially in patients of advanced age, and those affected by cardiovascular diseases and taking essential drugs. A highly selective -adrenergic blocker silodosin is characterized by a lower rate of mentioned adverse events, comparable with placebo. Silodosin is also highly effective in treating of both types of LUTS in these patients, both as monotherapy and in combination with other drugs. A detailed analysis of clinical data confirming the high efficacy and safety of silodosin is presented in this review of the literature.

[The effect of preservative-free treatment of primary open-angle glaucoma on the state of ocular surface in combination therapy (intermediate results)]. / Vliianie beskonservantnoi terapii pervichnoi otkrytougol'noi glaukomy na sostoianie glaznoi poverkhnosti pri kombinirovannom lechenii (promezhutochnye rezul'taty).

The goal of antihypertensive therapy is to reduce intraocular pressure (IOP). Sometimes it can only be achieved by using two or more drugs, which can lead to undesirable side effects on the ocular surface. The use of drugs that do not contain preservatives leads to fewer undesirable side effects, while also reducing the need for instillations of artificial tears, making it economically beneficial for patients. PURPOSE: To assess the state of ocular surface in patients with POAG when switching to preservative-free carbonic anhydrase inhibitor (ICA) containing 0.18% sodium hyaluronate in combination with prostaglandin analogues and beta-adrenergic blocking agents. MATERIAL AND METHODS: The study was conducted in 2019; according to selection criteria, it included 46 patients (80 eyes) with POAG and a control group of healthy persons. At the start of the study and one month later, after a change of treatment to uninterrupted ICA containing 0.18% sodium hyaluronate, the patients had state of their ocular surface examined: Norn's test (tear break-up time; TBUT), Schirmer's test, vital staining with lissamine green and an Ocular Surface Disease Index (OSDI) survey. RESULTS: Replacing the ICA with benzalkonium chloride in the combination therapy of glaucoma with a preservative-free ICA containing 0.18% sodium hyaluronate - Dorzolan Solo (Solopharm, Russia) - expectedly did not lead to additional decrease of IOP, but resulted in a decrease in the width of the confidence interval according to both Maklakov's and Icare tonometers, which may be associated with increased treatment adherence. At the same time, the state of ocular surface in the observation group was statistically significantly improved according to Norn's test - from 3.57±1.3; 3.0 (3.0; 5.0) to 4.9±2.5; 5.0 (3.0; 6.0) (V=16.5; p=0.0039). CONCLUSION: According to Schirmer's test and vital staining with lissamine green, no statistically significant changes have occurred. OSDI survey did not reveal changes in the study patients during 4 weeks of the follow-up, while the control group exhibited improvement.

[Comprehensive pharmacologic management of overactive bladder].

Overactive bladder (OAB) is a common and bothersome condition manifested by urgency, frequent urination, significantly impairing patients quality of life. The article presents an overview of the evidence on pharmacotherapy of neurogenic and idiopathic OAB. Selective M3 receptor blockers have been shown to be the medications of choice in treating these patients. Many studies have shown that solifenacin 10 mg is a starting dose for patients with OAB. Mirabegron (Betmiga) is the only 3-adrenergic receptor agonist approved for primary treatment of OAB patients refractory to anticholinergics or have their side effects. It seems promising to use this drug, both as monotherapy and concurrently with anticholinergic agents to improve treatment results in patients with idiopathic and neurogenic OAB.

[Validation of urgency scale to detect and assess urgency in patients with overactive bladder].

INTRODUCTION: Urinary urgency is a hallmark symptom of overactive bladder (OAB). Several scales have been used to measure urgency. Taking into account the exceptional importance of these scales, it is important to determine their reliability, which depends directly on the accuracy of the wording and clarity to patients. AIM: To determine reliability of Russian-language translation of the Patient Perception of Intensity of Urgency Scale (PPIUS) in identifying and assessing urgency in patients with OAB. MATERIALS AND METHODS: The study included 50 patients (46 women and 4 men) aged 19 to 70 years (mean age 56.5 years). At the time of entering the study, all patients had symptoms of OAB and received anticholinergic therapy for at least 3 months with any drug approved for the use in Russia. PPIUS scale validation was performed by assessing reliability, absence of "habituation" effect of and indicators of convergent, divergent, and content validity. RESULTS: The Russian version of voiding diary with PPIUS scale was found to have good psychometric properties and besides the content validity also had significant signs of convergent and divergent validity. CONCLUSION: The Russian-language versions of urgency scales PPIUS and TUFS can be considered validated for using in clinical practice and in clinical and non-interventional studies in patients with OAB in Russia.

[High doses of trospium chloride in patients with idiopathic overactive bladder. Data of large-scale, multicenter observational program Resource].

PURPOSE: Evaluation of the efficacy and safety of different doses of trospium chloride in patients with idiopathic overactive bladder. MATERIALS AND METHODS: Large-scale observational program "Resource" included 669 patients with idiopathic OAB - 359 women and 310 men. At the first visit, all patients were assigned to use of trospium chloride at a standard dose of 45 mg per day. The results of treatment were evaluated during follow-up visits at 3, 6, 9 and 12 weeks. Depending on the results of examination, the dose was reduced in the presence of adverse events and increased in case of insufficient treatment effects. RESULTS: After 12 weeks, 102 patients have been receiving the drug at a dose of 30 mg/day, 241 - at a dose of 45 mg/day, 257 - at a dose of 60 mg/day, and 22 - at a dose of 75 mg/day. CONCLUSIONS: Individual approach to the selection of doses of trospium chloride in patients with idiopathic OAB can be quite effective and safe measure to achieve optimal clinical outcome with a good safety profile.

[NERVE GROWTH FACTOR IN THE URINE OF PATIENTS WITH IDIOPATHIC DETRUSOR OVERACTIVITY AND OVERACTIVE BLADDER WITHOUT DETRUSOR OVERACTIVITY].

The purpose was to determine the concentration of the neurotrophin nerve growth factor in urine to assess its possible role as a marker in the diagnosis of various forms of overactive bladder. The study included patients with urinary frequency and urgency: 21 patients with idiopathic detrusor overactivity, 18--with overactive bladder without detrusor overactivity and 11 healthy volunteers (control group). The level of nerve growth factor in the urine was determined in all participants of the study by the enzyme immunoassay (ELISA). In the control group the average ratio of nerve growth factor level to the level of urine creatinine was 0.2 ± 0.06, in patients with overactive bladder without detrusor overactivity -0.33 ± 0.06 (p > 0.05). In patients with idiopathic detrusor overactivity the rate was significantly higher and amounted to 6.04 ± 0.9 (p < 0.05). Therefore, measurement of the concentration of nerve growth factor in the urine may be used for differential diagnosis of the presence or absence of detrusor overactivity in patients with overactive bladder.

[INJECTION OF BOTULINUM TOXIN TYPE A IN THE BLADDER DETRUSOR AND SUBMUCOSA IN PATIENTS WITH OVERACTIVE BLADDER WITHOUT DETRUSOR OVERACTIVITY].

The objective of the study was to compare the efficacy and safety of injections of botulinum toxin type A in the submucosal layer of the bladder and in detrusor in patients who were refractory to anticholinergic therapy of overactive bladder without detrusor overactivity. 100 U botulinum toxin type A was diluted in 10 ml of 0.9% saline and injected with 0.5 ml (5 units) of this solution in 20 points of the bladder (the back and side walls except Letto triangle). In twenty-two patients (the first group) botulinum toxin was injected into the submucosal layer of the bladder, while in 34 patients (second group) - into the detrusor. In the first group after 1 and 3 months 3 (14%) patients and after 6 months 2 (9%) patients had positive treatment outcomes (improvement of symptoms in more than 50%). In 22 (65%) of the 34 patients of the second group positive results were observed at 1 and 3 months and in 17 (50%) - at 6 months. After 9 months, all patients had a relapse of urgent and frequent urination. Difficulties in emptying the bladder were observed in three (9%) of the second group patients who had to resort to periodic self-catheterization for 2-20 weeks. The obtained results allow us to state that the injections of 100 U of botulinum toxin type A in the submucosal layer of the bladder are ineffective in patients with overactive bladder without detrusor overactivity, whereas injections in the detrusor lead to a statistically significant improvement in symptoms of urgent and frequent urination for 6 months.

[Long-term outcomes of the use of α-blockers tamsulosin in men with lower urinary tract symptoms and benign prostatic hyperplasia].

The retrospective evaluation of efficacy and safety of tamsulosin omnik (0.4 mg once a day) for 8 years in 17 patients with BPH and LUTS was performed. At the time of appointment of tamsulosin, mean age of patients was 61.9 years (range, 51 to 69 years). Efficacy of tamsulosin was evaluated based on the change of obstructive and irritative symptoms according to items of I-PSS scale, maximum urinary flow rate, residual urine volume and prostate volume. The study found that factors for favorable prognosis against the background of use of tamsulosin include moderate LUTS, small- or medium-sized BPH, maximum urinary flow rate of not less than 9 ml/s, and residual urine volume not more than 100 ml.

[Effectiveness of 3-hydroxypyridine and succinic acid derivatives in complex treatment of primary open-angle glaucoma].

Prospective, placebo-controlled, single-blind, randomized clinical investigation of the influence of domestic 3-hydroxypyridine and succinic acid derivatives (emoxipin, reamberin, mexidol) on the effectiveness of a complex treatment of primary open-angle glaucoma (POAG) has been performed in a group of patients. It is established that intravenous infusion of 3-hydroxypyridine derivatives (emoxipin and mexidol) for two weeks, beginning 14 days after the start of POAG treatment, produced a retinoprotective action, with three months postponed changes in the central retinal artery (CRA) blood velocity. The retinoprotective effect of emoxipin (single dose, 150 mg) was manifested by reduction in the horizontal size of blind spot in two weeks, with the subsequent reduction of the CRA end-diastolic blood velocity observed three months after finish of the infusion therapy. The administration of mexidol (single dose, 300 mg) after 14 days of treatment led to widening of the summarized field of vision (test-object square, 16 mm), accompanied by a decrease in the electrosensitivity threshold of the optic nerve and the intensity of POAG-associated hypothymia. All indices of CRA blood velocity increased three months after termination of mexidol infusions. Reamberin (single dose, 400 ml 1,5% solution of reamberine, containing polyelectrolyte and meglumine succinate mixture) did not show retinoprotective action, but caused proatherogenic changes of blood lipids and 3 months postponed CRA end-diastolic blood velocity increase. The effect of mexidol (which is a derivative of both 3- hydroxypyridine and succinic acid) exceeds that of separate 3-hydroxypyridine (emoxipin) and succinic acid (reamberin) derivatives in the degree of retinoprotection and positive effect on the optic nerve condition and mood of POAG patients.

[The influence of water soluble antioxidant agent (mexidol) on optic nerve and blood flow velocity in ocular and orbital arteries in patients with primary open-angle glaucoma].

The prospective single-blind placebo-controlled randomized trial is devoted to influence of mexidol (2-ethil-6-methil-3-hydroxipiridine succinate) on dynamics of optic nerve electrophysiologic profile and velocity indices of blood flow in ocular and orbital arteries in correlation with changes of retinal photosensitivity, visual acuity and visual field size during course of intravenous mexidol infusions and standard treatment of primary open-angle glaucoma. 2 weeks of intravenous infusions of 300 mg mexidol daily was found to cause depression of optic nerve electrical sensitivity threshold and widening of total visual field (16 mm2 test stimulus) after 14 days of treatment. These effects were not associated with changes of blood flow velocity in ocular and orbital arteries, were transient and came to initial indices 3 months after the end of treatment. Delayed vasotropic effect of mexidol manifested in increase of blood flow velocity in central retinal artery in 90 days after the end of infusions.

[Botulinic toxin type a in combined treatment of males with chronic pelvic pain syndrome in combination with bladder emptying dysfunction].

The efficacy of various treatment of chronic pelvic pain syndrome in combination with bladder emptying dysfunction was comparatively analysed for 31 male patients. Statistics show that current schemes of medication including antibacterial, nonsteroid anti-inflammatory drugs, alpha-adrenoblockers are not highly effective in such patients. Transrectal microwave hyperthermia is effective in males with chronic pelvic pain syndrome but the response is short - 3 months maximum. The highest and the longest effect in patients with chronic pelvic pain syndrome in combination with bladder emptying dysfunction was achieved after injections of 100 units of botulinic toxin type A into the cross-striated sphincter of the urethra.

[Botulinum toxin type A in patients with overactive bladder].

The aim of the study was to investigate safety and efficacy of intradetrusor injection of 100 units of botulinum toxin type A in 26 patients with refractory overactive bladder. The diagnostic scheme consisted of 72 h diary, laboratory tests, ultrasound investigation with measurement of residual urine, urodynamic investigation and neurological examination. The patients were divided into 3 groups: 14 patients with idiopathic detrusor overactivity (DO), 9 with neurogenic DO, and 6 with overactive bladder without DO. 100 units of botulinum toxin type A mixed with 20 ml of normal saline were injected into the detrusor sparing the trigone. Clinical and urodynamic evaluations were performed before the injection and 1, 3 and 6 months after it. The patients with idiopathic DO and overactive bladder without DO showed improvement of such clinical symptoms as frequency, urgency, nocturia and urgent incontinence which lasted for at least 6 months. Patients with neurogenic DO had improvement of the clinical symptoms only for one month after treatment. We had no patients who exhibited acute urinary retention or residual urine. Thus, 100 units of botulinum toxin type A injected into the detrusor is an effective, safe and well tolerated treatment for patients with idiopathic DO and overactive bladder without DO in whom an anticholinergic medication has failed.

Minocycline-induced cutaneous hyperpigmentation: confocal laser scanning microscope analysis.

BACKGROUND: Minocycline has a characteristic yellow-green fluorescent emission. This fluorescence has been previously demonstrated only in type 1 minocycline-induced skin hyperpigmentation. OBJECTIVE: To investigate whether the fluorescence can be detected in other types of minocycline-induced cutaneous hyperpigmentation, and to study the possible mechanisms. METHODS: Biopsies of pigmented and nonpigmented skin from 3 patients with different types of skin hyperpigmentation induced by minocycline were analysed by light microscopy and Confocal Laser Scanning Microscope (CLSM). RESULTS: A yellow-green fluorescence was observed in the hyperpigmented skin of two patients with type 2, and one patient with type 4 minocycline-induced cutaneous hyperpigmentation. No fluorescence was detected in the non-pigmented skin. CONCLUSION: Minocycline can possibly serve as a fluorescent probe in the diagnosis of all types of minocycline-induced cutaneous hyperpigmentation.

Estudio comparativo de tres variantes del ensayo de la membrana corioalantoidea del huevo de la gallina para la evaluación de la irritación ocular / Ocular irritation of chemicals measured by three different protocols based on the hen's egg test on the chorioallantoic membrane

Durante los últimos años se han desarrollado varias alternativas con el objetivo de reemplazar la prueba de irritación ocular en el conejo. El objetivo de este trabajo fue comparar la utilidad de tres protocolos diferentes de la prueba de la membrana corioalantoidea del huevo de gallina, descrita en una base de datos establecida de técnicas de Toxicología in vitro, evaluando la irritación potencial de diez sustancias químicas y formulaciones. Se compararon los datos con aquellos obtenidos en la prueba animal tradicional. Se halló una buena correlación con los datos del test in vivo para dos de los protocolos usados, en que tres sustancias fueron clasificadas como no irritantes y siete como irritantes en alguna magnitud. Sin embargo, se encontraron seis falsos negativos con la tercera prueba usada. Se discuten posibles causas para estos, resultados. De las tres técnicas estudiadas la mejor es la que se basa en la utilización de azul de tripano ya que se trata de una técnica más rápida, de más fácil realización y con un resultado más fiable al evaluar los daños ocasionados en la membrana corioalantoidea de una forma objetiva y cuantificable (AU)

Evaluación de la irritación ocular mediante un ensayo de hemólisis y desnaturalización de la hemoglobina in vitro / Ocular irratation assessed in vitro by a hemolysis and hemoglobin denaturation test

La creciente tendencia a reducir, refinar y reemplazar los experimentos con animales, unida a los adelantos tecnológicos de nuestros días, ha favorecido el surgimiento y pujante desarrollo que hoy alcanza en el mundo la Toxicología in vitro. Como alternativa al test de Draize, se utilizó un ensayo para evaluar el potencial de irritación ocular mediante la hemólisis y la desnaturalización de la hemoglobina, ocasionadas al enfrentar la sustancia en estudio, a distintas concentraciones, con una suspensión de glóbulos rojos cuya densidad era conocida. Se evaluó el potencial de irritación de 20 productos limpiadores provenientes de empresas cubanas, de los cuales se clasificaron tres como moderadamente irritantes, dieciséis como irritantes y uno como muy irritante. Fueron utilizadas, además, tres sustancias de referencia corno controles. Se encontró una total correspondencia con los resultados de los estudios in vivo para los productos y las sustancias evaluadas. El ensayo mostró sensibilidad, especificidad y capacidad de predicción óptimas, al clasificar como irritantes la totalidad de los productos, coincidiendo con la clasificación que los mismos tuvieron in vivo. También se obtuvo coincidencia de los resultados in vivo / in vitro para las sustancias de referencia incluidas en el estudio. Se recomienda la utilización del test de hemólisis y desnaturalización de la hemoglobina como parte de una batería de ensayos dirigida hacia la evaluación toxicológica de productos de limpieza que contienen sustancias tensioactivas en su formulación (AU)

Pemphigus vulgaris: environmental factors. Occupational, behavioral, medical, and qualitative food frequency questionnaire.

BACKGROUND: There have been reports suggesting the involvement of environmental factors in the disease process of pemphigus. Factors suggested include exposure to pesticides or certain drugs. OBJECTIVE: To analyze the association of pemphigus with environmental exposure to various agents, including smoking, recreational and occupational insults, drugs, and food. DESIGN AND SETTING: In-person interviews of pemphigus patients and control subjects were conducted by trained medical investigators using a structured questionnaire. Questions included occupational, behavioral, medical, and qualitative food frequency details. The multicenter study was conducted at outpatient services of teaching hospitals in Bulgaria, Brazil, India, Israel, Italy, Spain, and the USA. PARTICIPANTS: A total of 126 pemphigus patients (55 men, 71 women; age, 54 +/- 17 years) and 173 healthy controls (87 men, 86 women; age 50 +/- 19 years) were interviewed in the period between October 1, 1999 and March 31, 2000. The diagnosis of pemphigus was based on clinical, histologic, immunohistologic, and immunohistochemical criteria. The disease duration was 2-27 years (8.4 +/- 7.2 years). Individuals with skin diseases other than pemphigus were selected as control subjects. MAIN OUTCOME MEASURE: Information on drugs, foods, and occupational, environmental, constitutional, and other possible risk factors was analyzed by t-tests and chi-squared tests as applicable. A multivariate logistic regression model was applied to the data to study simultaneously the independent relationship between each risk factor and pemphigus vulgaris. RESULTS: The risk for pemphigus vulgaris was lower for ex-smokers and current smokers than for patients who had never smoked. Exposure to pesticides and occupational exposure to metal vapor were associated with an increased risk of pemphigus. Pemphigus patients had more pregnancies than controls. There were differences in environmental factors between countries, with exposure to gardening materials and pesticides being highest among patients from Bulgaria, followed by Israel. Disease characteristics also exhibited differences between countries. Bulgarian patients less frequently had oral mucous membrane lesions: 66% compared to 92% for Israeli patients and 83% for Italians. The distribution of the disease in skin and mucous membranes was similar among patients from all countries. Exclusive skin involvement was seen in 50% of patients, mucous membranes alone in 23% of patients, and both skin and mucous membranes in 27% of patients. CONCLUSIONS: The beneficial effect of smoking on pemphigus might be explained by its effect on the immune system. In addition, smoking has an antiestrogenic effect, while pesticides have an estrogenic effect. The lower numbers of smokers among patients, the higher exposure rates to pesticides, and the higher number of female patients who had been pregnant may point to the contribution of estrogens to the disease process. It remains to be determined whether measures, such as avoiding exposure to pesticides or metal vapor, may be beneficial in the clinical context. As the present study was a survey, more definitive studies should be conducted to validate the results.

In vitro tannin acantholysis.

BACKGROUND: Exogenous factors, such as certain drugs, may be involved in the induction of pemphigus. Other offenders sharing a similar chemical composition to these drugs may also play a role. Tannins with their considerable biologic activity were suggested as possible factors. To substantiate the role of tannins in the pathomechanism of pemphigus, the present study examined the acantholytic potential of tannins in vitro. METHODS: Normal human breast skin from patients without any bullous disease was cultured for 3 days in the presence of tannic acid at concentrations of 0.02, 0.05, 0.1, 0.25, 0.5, 1.0, and 2.0 mM. The effect of the tannic acid was microscopically examined in a blind fashion by three independent investigators. RESULTS: In addition to the cytotoxic effect, tannic acid caused marked acantholytic changes, with a clear suprabasal cleavage and intraepidermal acantholytic cells. The acantholytic changes were the most constant and specific effects. They were constantly observed at 1.0 and 2.0 mM, whereas lower concentrations showed changes only in some of the explants. The concentrations needed to exert this effect were notably low. There was a remarkable variability among the subjects who had provided the explants. CONCLUSIONS: The results suggest a possible role of tannin in the disease process of pemphigus. The tannin acantholytic potential was much greater than the potential of known acantholytic drugs, such as penicillamine and captopril. The interindividual variability in susceptibility to acantholysis may explain the variability in the individual potential for developing pemphigus.

Computerized system to enhance the clinical diagnosis of pigmented cutaneous malignancies.

BACKGROUND: An increase in the incidence of cutaneous malignant melanoma in recent years has not been accompanied by satisfactory progress in diagnostic methods. This study was carried out to evaluate a specially designed computerized image analysis system, called Derma Vision, to aid in the differentiation between malignant and benign cutaneous pigmented lesions. METHODS: Seventy-one lesions were photographed with a digital camera and the data were analyzed by the Derma Vision system. The system assessed the variation of hues in each image, calculated the mean standard deviation of the hues, and produced a value that expressed the range of hues in the lesion. The lesions were then excised and examined histologically. The computer-assisted clinical diagnosis was correlated with the histologic diagnosis to determine the accuracy of the former. RESULTS: Derma Vision predicted the malignant character of a lesion with 92% precision, compared with 87% accuracy based only on the clinical features. CONCLUSIONS: This simple, inexpensive device can boost the accuracy of clinical diagnosis and provide a useful tool to the physician faced increasingly with having to determine whether pigmented lesions are malignant or benign.

Pemphigus and pemphigoid-like effects of nifedipine on in vitro cultured normal human skin explants.

BACKGROUND: A variety of drugs have been implicated in the onset and exacerbation of pemphigus and bullous pemphigoid. The demonstration of biochemical acantholysis in skin explants to various drugs in the absence of autoantibodies, in which the tested drugs evoke a biochemical reaction that leads to desmosomal function loss, may be a valuable adjunct to patient management by confirming the suspicion of drug-related pemphigus or bullous pemphigoid. OBJECTIVE: To determine whether a skin explant model might serve as a possible in vitro correlate of drug-induced pemphigus and pemphigoid-like effects related to the calcium channel blocker nifedipine. METHODS: Normal human breast skin obtained from nonpemphigus and nonpemphigoid patients undergoing mastectomy was cultured with nifedipine at final concentrations of 2, 4, and 8 mM. The drug effect on skin explants evidenced by morphologic changes was evaluated by microscopy by three observers. RESULTS: Five out of seven explants cultured with nifedipine at concentrations ranging from 2 to 8 mM exhibited obvious morphologic changes of two types: intraepithelial (or pemphigus-type) splittings and subepithelial (or pemphigoid-type) splittings. Two explants showed no acantholysis and no subepithelial splittings. Control cultures without polyethylene glycol 200 (PEG) showed no changes. Skin control samples cultured in medium supplemented with 10% PEG displayed vacuolar degeneration throughout the entire epidermis, but no sign of cell-cell dyshesion or dermo-epidermal detachment. CONCLUSIONS: A type of skin susceptibility to nifedipine may be genetically determined, with some nifedipine-treated patients developing an acantholytic reaction and others a subepidermal bullous eruption.

Diet and pemphigus. In pursuit of exogenous factors in pemphigus and fogo selvagem.

Individuals with a genetic predisposition to pemphigus will develop the disease only when one or more additional factors are present. The nature of these factors is as yet unknown, but our starting point was that certain drugs (penicillamine, captopril, and rifampicin) are recognized as such factors. Since some nutrients have chemical compositions similar to these known causative drugs, these nutrients may act similarly and, therefore, nutritional factors should also be suspected. As when drugs are involved, elimination of the inciting ingredients may be crucial for management of the disease. This article discusses the possible role of nutritional ingredients in the disease process of pemphigus, including fruit, leaves, roots, seeds, and even water. Possible causative candidates are thiol, thiocyanate, phenols, and tannins.